THE VIKING OFFICE WILL RECEIVE AND EVALUATE YOUR REFILL REQUEST. IF APPROVED, THE PAYMENT INFORMATION SPECIFIED WILL BE CHARGED AND THE ORDER PROCESSED AND SUBMITTED TO THE PHARMACY. Date MM slash DD slash YYYY Email* Enter Email Confirm Email Name* First Last Date of Birth* MM slash DD slash YYYY Phone*Drivers License Number StateChoose StateChoose your stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificRequested refill for the following medications:*Note: If a medication is outside of your already approved protocol you will need to schedule a consultation before we can send any new medication. ALSO: It is required that your lab results be less than 6 months old at all times. Please schedule labs prior to refill order if needed!Billing Address****We cannot ship to a PO Box - we need an actual street address in order to ship your medication. *** Street Address Address Line 2 City ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHPuerto RicoOKORPAPRRISCSDTNTXUTVIVTVAWAWVAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanWIWY State ZIP Code Is your shipping address the same as billing address? Yes ***We cannot ship to a PO Box - we need an actual street address in order to ship your medication. *** Shipping Address* Street Address Address Line 2 City ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHPuerto RicoOKORPAPRRISCSDTNTXUTVIVTVAWAWVAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanWIWY State ZIP Code ***We can only ship to your residential address. We cannot ship to a PO Box - we need an actual street address in order to ship your medication. *** Pay with Cryptocurrency YES NO Cardholder's Name Credit Card Card Type American Express Discover Mastercard Visa HSA Expiration Date Expiration Year Security Code